Statistics in Medicine 4th Edition

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Statistics in Medicine
Statistics in Medicine
Fourth Edition

ROBERT H. RIFFENBURGH
Department of Mathematics and Statistics, San Diego State University,
San Diego, CA, United States

DANIEL L. GILLEN
Department of Statistics, Program in Public Health, & Department of
Epidemiology, University of California, Irvine, CA, United States
Academic Press is an imprint of Elsevier
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can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional practices,
or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
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instructions, or ideas contained in the material herein.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
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A catalog record for this book is available from the Library of Congress
ISBN: 978-0-12-815328-4
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visit our website at https://www.elsevier.com/books-and-journals

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DEDICATION

To my children and grandchildren and to the very many medical investigators I have
been privileged to work with.
RHR

To Lilli, Elise, Sienna, my mother Sharon, and all my collaborators over the years.
DLG
When told, “I’m too busy treating patients to do research,” we answer:

When you treat a patient, you treat one patient.

When you do research, you treat 10,000 patients.
 Contents

Foreword to the fourth edition xvii

Acknowledgments xxi
How to use this book? xxiii

1. Planning studies: from design to publication 1

1.1 Organizing a Study 1
1.2 Stages of Scientific Investigation 1
1.3 Science Underlying Clinical Decision-Making 3
1.4 Why Do We Need Statistics? 5
1.5 Concepts in Study Design 7
1.6 Study Types 8
1.7 Convergence With Sample Size 11
1.8 Sampling Schemes in Observational Studies 11
1.9 Sampling Bias 13
1.10 Randomizing a Sample 15
1.11 How to Plan and Conduct a Study 16
1.12 Mechanisms to Improve Your Study Plan 17
1.13 Reading Medical Articles 19
1.14 Where Articles May Fall Short 19
1.15 Writing Medical Articles 22
1.16 Statistical Ethics in Medical Studies 23
1.17 Conclusion 27
Appendix to Chapter 1 28

2. Planning analysis: how to reach my scientific objective 29

2.1 What Is in This Chapter 29
2.2 Notation (or Symbols) 29
2.3 Quantification and Accuracy 31
2.4 Data Types 32
2.5 Multivariable Concepts and Types of Adjustment Variables 35
2.6 How to Manage Data 37
2.7 Defining the Scientific Goal: Description, Association Testing, Prediction 40
2.8 Reporting Statistical Results 41
2.9 A First-Step Guide to Descriptive Statistics 42

ix
x Contents

2.10 An Overview of Association Testing 45

2.11 A Brief Discussion of Prediction Modeling 50

3. Probability and relative frequency 51

3.1 Probability Concepts 51
3.2 Probability and Relative Frequency 55
3.3 Graphing Relative Frequency 56
3.4 Continuous Random Variables 57
3.5 Frequency Distributions for Continuous Variables 58
3.6 Probability Estimates From Continuous Distributions 62
3.7 Probability as Area Under the Curve 63
References 64

4. Distributions 65
4.1 Characteristics of a Distribution 65
4.2 Greek Versus Roman Letters 65
4.3 What Is Typical 65
4.4 The Spread About the Typical 68
4.5 The Shape 69
4.6 Sampling Distribution of a Variable Versus a Statistic 71
4.7 Statistical Inference 72
4.8 Distributions Commonly Used in Statistics 75
4.9 Approximate Distribution of the Mean (Central Limit Theorem) 83
4.10 Approximate Distribution of a Sample Quantile 86

5. Descriptive statistics 89
5.1 Purpose of Descriptive Statistics 89
5.2 Numerical Descriptors, One Variable 89
5.3 Numerical Descriptors, Two Variables 95
5.4 Numerical Descriptors, Three Variables 100
5.5 Graphical Descriptors, One Variable 101
5.6 Graphical Descriptors, Two Variables 110
5.7 Graphical Descriptors, Three Variables 111
5.8 Principles of Informative Descriptive Tables and Figures 114
References 115

6. Finding probabilities 117

6.1 Probability and Area Under the Curve 117
6.2 The Normal Distribution 117
6.3 The t Distribution 121
6.4 The Chi-Square Distribution 124
6.5 The F-Distribution 127
 Contents xi

6.6 The Binomial Distribution 130

6.7 The Poisson Distribution 132
References 135

7. Hypothesis testing: concept and practice 137

7.1 Hypotheses in Inference 137
7.2 Error Probabilities 144
7.3 Two Policies of Testing 148
7.4 Distinguishing Between Statistical and Clinical Significance 150
7.5 Controversies Regarding the Rigid Use and Abuse of p-Values 151
7.6 Avoiding Multiplicity Bias 152
7.7 Organizing Data for Inference 152
7.8 Evolving a Way to Answer Your Data Question 156
Reference 159

8. Tolerance, prediction, and confidence intervals 161

8.1 Overview 161
8.2 Tolerance Intervals for Patient Measurements 163
8.3 Concept of a Confidence Interval for a Parameter 164
8.4 Confidence Interval for a Population Mean, Known Standard Deviation 166
8.5 Confidence Interval for a Population Mean, Estimated Standard Deviation 169
8.6 Confidence Interval for a Population Proportion 171
8.7 Confidence Interval for a Population Median 175
8.8 Confidence Interval for a Population Variance or Standard Deviation 176
8.9 Confidence Interval for a Population Correlation Coefficient 179
References 181

9. Tests on categorical data 183

9.1 Categorical Data Basics 183
9.2 Tests on Categorical Data: 2 3 2 Tables 185
9.3 The Chi-Square Test of Contingency 186
9.4 Fisher’s Exact Test of Contingency 190
9.5 Tests on r 3 c Contingency Tables 192
9.6 Tests of Proportion 195
9.7 Tests of Rare Events (Proportions Close to Zero) 201
9.8 McNemar’s Test: Matched Pair Test of a 2 3 2 Table 205
9.9 Cochran’s Q: Matched Pair Test of a 2 3 r Table 210
9.10 Three or More Ranked Samples With Two Outcome Categories: Royston’s Ptrend Test 211
References 213

10. Risks, odds, and receiver operating characteristic curves 215

10.1 Association Measures for Categorical Data: Risks and Odds 215
10.2 Inference for the Risk Ratio: The Log Risk Ratio Test 225
xii Contents

10.3 Inference for the Odds Ratio: The Log Odds Ratio Test 227
10.4 Receiver Operating Characteristic Curves 232
10.5 Comparing Two Receiver Operating Characteristic Curves 235
References 237

11. Tests of location with continuous outcomes 239

11.1 Basics of Location Testing 239
11.2 Single or Paired Means: One-Sample Normal (z) and t Tests 241
11.3 Two Means: Two-Sample Normal (z) and t Tests 245
11.4 Three or More Means: One-Factor Analysis of Variance 256
11.5 Three or More Means in Rank Order: Analysis of Variance Trend Test 265
11.6 The Basics of Nonparametric Tests 267
11.7 Single or Paired Sample Distribution(s): The Signed-Rank Test 269
11.8 Two Independent Sample Distributions: The Rank-Sum Test 272
11.9 Large Sample-Ranked Outcomes 276
11.10 Three or More Independent Sample Distributions: The Kruskal Wallis Test 280
11.11 Three or More Matched Sample Distributions: The Friedman Test 284
11.12 Three or More Ranked Independent Samples With Ranked Outcomes:
Cusick’s Nptrend Test 287
11.13 Three or More Ranked Matched Samples With Ranked Outcomes: Page’s L Test 290
11.14 Potential Drawbacks to Using Nonparametric Tests 291
Reference 294

12. Equivalence testing 295

12.1 Concepts and Terms 295
12.2 Basics Underlying Equivalence Testing 296
12.3 Choosing a Noninferiority or Equivalence Margin 299
12.4 Methods for Noninferiority Testing 300
12.5 Methods for Equivalence Testing 304
12.6 Joint Difference and Equivalence Testing 307
References 309

13. Tests on variability and distributions 311

13.1 Basics of Tests on Variability 311
13.2 Testing Variability on a Single Sample 312
13.3 Testing Variability Between Two Samples 315
13.4 Testing Variability Among Three or More Samples 317
13.5 Basics on Tests of Distributions 321
13.6 Test of Normality of a Distribution 322
13.7 Test of Equality of Two Distributions 331
References 336

14. Measuring association and agreement 337

14.1 What Are Association and Agreement? 337
 Contents xiii

14.2 Contingency as Association 338

14.3 Correlation as Association 342
14.4 Contingency as Agreement 344
14.5 Correlation as Agreement 345
14.6 Agreement Among Ratings: Kappa 346
14.7 Agreement Among Multiple Rankers 348
14.8 Reliability 353
14.9 Intraclass Correlation 354
References 355
15. Linear regression and correlation 357
15.1 Introduction 357
15.2 Regression Concepts and Assumptions 359
15.3 Simple Regression 363
15.4 Assessing Regression: Tests and Confidence Intervals 368
15.5 Deming Regression 376
15.6 Types of Regression 378
15.7 Correlation Concepts and Assumptions 379
15.8 Correlation Coefficients 382
15.9 Correlation as Related to Regression 384
15.10 Assessing Correlation: Tests and Confidence Intervals 385
15.11 Interpretation of Small-But-Significant Correlations 390
References 390

16. Multiple linear and curvilinear regression and multifactor analysis of variance 391
16.1 Introduction 391
16.2 Multiple Linear Regression 396
16.3 Model Diagnosis and Goodness of Fit 407
16.4 Accounting for Heteroscedasticity 412
16.5 Curvilinear Regression 414
16.6 Two-Factor Analysis of Variance 420
16.7 Analysis of Covariance 426
16.8 Three-Way and Higher Way Analysis of Variance 430
16.9 Concepts of Experimental Design 431
References 435

17. Logistic regression for binary outcomes 437

17.1 Introduction 437
17.2 Extensions of Contingency Table Analyses Simple Logistic Regression 438
17.3 Multiple Logistic Regression: Model Specification and Interpretation 441
17.4 Inference for Association Parameters 445
17.5 Model Diagnostics and Goodness-of-Fit 448
References 457
xiv Contents

18. Poisson regression for count outcomes 459

18.1 Introduction 459
18.2 The Poisson Distribution 459
18.3 Means Versus Rates 460
18.4 Inference for the Rate of a Poisson Random Variable 461
18.5 Comparing Poisson Rates From Two Independent Samples 463
18.6 The Simple Poisson Regression Model 465
18.7 Multiple Poisson Regression: Model Specification and Interpretation 469
18.8 Obtaining Predicted Rates 472
18.9 Inference for Association Parameters 473
Reference 475
19. Analysis of censored time-to-event data 477
19.1 Survival Concepts 477
19.2 Censoring 478
19.3 Survival Estimation: Life Table Estimates and Kaplan Meier Curves 480
19.4 Survival Testing: The Log-Rank Test 484
19.5 Adjusted Comparison of Survival Times: Cox Regression 487
References 490
20. Analysis of repeated continuous measurements over time 491
20.1 Introduction 491
20.2 Distinguishing Longitudinal Data From Time-Series Data 492
20.3 Analysis of Longitudinal Data 493
20.4 Time-Series: 514
References 531
21. Sample size estimation 533
21.1 Issues in Sample Size Considerations 533
21.2 Is the Sample Size Estimate Adequate? 536
21.3 The Concept of Power Analysis 537
21.4 Sample Size Methods 540
21.5 Test on One Mean (Normal Distribution) 541
21.6 Test on Two Means (Normal Distribution) 542
21.7 Tests When Distributions Are Nonnormal or Unknown 545
21.8 Test With No Objective Prior Data 546
21.9 Confidence Intervals on Means 547
21.10 Test of One Proportion (One Rate) 549
21.11 Test of Two Proportions (Two Rates) 551
21.12 Confidence Intervals on Proportions (On Rates) 553
21.13 Test on a Correlation Coefficient 555
21.14 Tests on Ranked Data 557
21.15 Variance Tests, Analysis of Variance, and Regression 558
 Contents xv

21.16 Equivalence Tests 558

21.17 Number Needed to Treat or Benefit 559
References 562
22. Clinical trials and group sequential testing 565
22.1 Introduction 565
22.2 Fundamentals of Clinical Trial Design 568
22.3 Reducing Bias in Clinical Trials: Blinding and Randomization 573
22.4 Interim Analyses in Clinical Trials: Group Sequential Testing 577
References 582
23. Epidemiology 583
23.1 The Nature of Epidemiology 583
23.2 Some Key Stages in the History of Epidemiology 584
23.3 Concept of Disease Transmission 584
23.4 Descriptive Measures 586
23.5 Types of Epidemiologic Studies 589
23.6 Retrospective Study Designs: The Case Control Study Design 591
23.7 The Nested Case Control Study Design 593
23.8 The Case Cohort Study Design 594
23.9 Methods to Analyze Survival and Causal Factors 594
23.10 A historical note 598
References 599
24. Meta-analyses 601
24.1 Introduction 601
24.2 Publication Bias in Meta-analyses 602
24.3 Fixed- and Random-Effects Estimates of the Pooled Effect 603
24.4 Tests for Heterogeneity of Estimated Effects Across Studies 606
24.5 Reporting the Results of a Meta-analysis 606
24.6 Further References 607
References 608
25. Bayesian statistics 609
25.1 What Is Bayesian Statistics 609
25.2 Bayesian Concepts 612
25.3 Describing and Testing Means 613
25.4 On Parameters Other Than Means 617
25.5 Describing and Testing a Rate (Proportion) 617
25.6 Conclusion 619
References 619

26. Questionnaires and surveys 621

26.1 Introduction 621
xvi Contents

26.2 Surveys 621

26.3 Questionnaires 624

27. Techniques to Aid Analysis 631

27.1 Interpreting Results 631
27.2 Significance in Interpretation 632
27.3 Post Hoc Confidence and Power 633
27.4 Multiple Tests and Significance 635
27.5 Bootstrapping, Resampling, and Simulation 639
27.6 Bland-Altman Plot: A Diagnostic Tool 642
27.7 Cost Effectiveness 647
References 649

28. Methods you might meet, but not every day 651
28.1 Overview 651
28.2 Analysis of Variance Issues 651
28.3 Regression Issues 652
28.4 Rates and Proportions Issues 653
28.5 Multivariate Methods 653
28.6 Markov Chains: Following Multiple States through Time 656
28.7 Markov Chain Monte Carlo: Evolving Models 657
28.8 Markov Chain Monte Carlo: Stationary Models 659
28.9 Further Nonparametric Tests 659
28.10 Imputation of Missing Data 660
28.11 Frailty Models in Survival Analysis 660
28.12 Bonferroni “Correction” 661
28.13 Logit and Probit 661
28.14 Adjusting for Outliers 661
28.15 Curve Fitting to Data 662
28.16 Sequential Analysis 663
28.17 Another Test of Normality 665
28.18 Data Mining 665
28.19 Data Science and The Relationship Among Statistics, Machine Learning, and Artificial
Intelligence 666
References 667

Appendix 1: Answers to exercises: Final 669

Appendix 2: Databases 717
Appendix 3: Tables of probability distributions 741
Appendix 4: Symbol index 761
Statistical Subject Index 765
Medical Subject Index 789
 Foreword to the fourth edition

The use of statistics in medical studies has revolutionized our understanding of human
health in the past 70 years or so. Early and classic examples include measuring the suc-
cess of the polio vaccine in the 1950s, and understanding the relationship between
smoking and lung cancer that led to the Surgeon General’s warning on cigarettes start-
ing in 1970. Since that time hundreds of thousands of medical studies have reaped the
benefit of the use of statistical methods.
This update of Statistics in Medicine continues the philosophy of Riffenburgh’s first
three editions, providing a nontechnical, comprehensible guide to most of the com-
mon statistical methods used to collect, analyze, and report data used in medical stud-
ies. Whether you are a medical practitioner, a student studying medicine, or a
layperson who wants to understand research about your own health issues or those of
a loved one, this book will guide you through what you need to know to understand
medical research results. If you are a practicing medical researcher, this book will pro-
vide you with the tools, vocabulary, and understanding needed to work collabora-
tively with a professional statistician. While it may seem like there are too many
statistical methods to cover in one book of this nature, the fact is that a large majority
of medical studies use just a small handful of common methods, all covered in this
book.
The fourth edition of this book brings many new features, including an additional
author, Professor Daniel L. Gillen. Professor Gillen has extensive experience working
with medical researchers on a range of diseases, including cancer and Alzheimer’s and
has consulted extensively with the Food and Drug Administration and the biopharma-
ceutical industry. As a professor, he is a highly acclaimed teacher and mentor for stu-
dents in both statistics and medical fields and has made substantial contributions to
biostatistical methodology. Adding Professor Gillen’s expertise to that of Professor
Riffenburgh, who wrote the first three editions of the book and has several decades of
experience as a statistical collaborator, means that there is almost no area of medicine
or biostatistics that is not familiar to one or both authors.
The book begins where you should begin if you want to understand the process of
medical research—with an overview of the process, including a step-by-step guide on
how to plan a successful study and avoid common mistakes. Even if you never plan or
implement your own research study, this guide will help you assess strengths and
weaknesses when you read the medical literature. That section is just one small exam-
ple of the focus this book places on understanding best practices and detecting

xvii
xviii Hypothesis testing: Concept and practice

common errors. The first two chapters set the stage for later chapters and include
almost no formulas. There are an additional 26 chapters, for a total of 28. Chapters
3 25 cover the myriad of statistical methods most commonly used in medical
research. Notable and unusual in a book of this type are the final two chapters:
Chapter 27 titled “Techniques to aid analysis,” discusses subtleties that can affect the
interpretation of results, and Chapter 28 has the self-explanatory title “Methods you
might meet, but not every day.”
There are five new chapters in this fourth edition, as well as new subsections in
existing chapters. The new chapters cover statistical methods that are occurring with
increasing frequency in the medical research literature. These include logistic regres-
sion, Poisson regression, longitudinal and time-series analyses, group sequential analy-
sis, and metaanalysis. Despite the sophistication of some of these methods, these
chapters focus on conceptual understanding. The methods are illustrated with several
examples, including interpretations of the models and results.
There are 17 real data sets accompanying the book, and an additional 20 data sets
available from the publisher’s website, covering a wide range of medical issues. Two
of the data sets are new to this edition, obtained from Professor Gillen’s work with
the Alzheimer’s Disease Research Center at the UCI. All of the data sets are used in
examples throughout the book, and in addition to downloadable files of the data, a
background description is provided for each one.
Artificial intelligence, machine learning, and data mining are all techniques
(described in Chapter 28: Methods you might meet, but not every day) being used to
produce “black box” algorithms that allegedly replace human judgment for medical
diagnosis and care. But these methods and algorithms are only as good as the data used
to create them. For many decades, statisticians have developed and refined appropriate
methods for collecting and understanding data and are aware of the dangers of overin-
terpreting results based on poorly designed studies. Now, more than ever, medical
practitioners need a book like Statistics in Medicine to understand the importance of
every stage of the design and implementation of medical studies in producing useful
and accurate results.
Professor Emerita Jessica Utts
University of California, Irvine, Irvine, CA, United States


Dr. Jessica Utts, Professor Emerita of Statistics at the University of California, Irvine (UCI), has served
as the Chair of the Department of Statistics at UCI, and Associate Vice Provost of University Outreach
at UC Davis, where she was on the faculty for 30 years prior to moving to UCI. She was the President
of the American Statistical Association in 2016 and President of the International Biometric Society,
Western North American Region, in 1986. She served as the Chief Reader for the Advanced
Placement Statistics Exam from 2014 to 2018. Professor Utts is internationally recognized for her work
in parapsychology and her ability to bring statistical literacy to the masses.
 Foreword to the fourth edition xix

ABSTRACTS OF FOREWORDS TO PRIOR EDITIONS

(Affiliations are listed as of when the Foreword was written.)
Foreword to the first Vice Admiral Richard A. Nelson, MD, USN
edition:
Surgeon General of the Navy Chief, Bureau of Medicine and
Surgery

We have a critical obligation not only to care for our patients but also to assess thor-
oughly our decisions on therapy, treatments effects, and outcomes. Scientifically rigorous
medical studies, including sound statistical analyses are central to this process. In recent years,
statistical analysis has become the hallmark of studies appearing in the leading journals.
This book represents a practical opportunity for health-care trainees and staff not
only to acquaint themselves with statistics in medicine and understand statistical analy-
sis in the medical literature but also to be guided in the application of planning and
analysis in their own medical studies.

***
Foreword to the W.M. (Mike) O’Fallon, PhD
second edition:
Professor Emeritus of Biostatistics, Mayo Clinic; Chair,
Department of Health Science Research Past President, American
Statistical Association

To refer to the last century as revolutionary in the statistical world would be a

gross understatement. I believe the effects of this revolution are more profound in the
world of medicine and other health-related sciences than in most scientific disciplines.
Dr. Riffenburgh addresses just this problem in his successful book on statistics in
medicine (presenting) statistics in language accessible to health-care practitioners so
that they could effectively understand and communicate statistical information.

***
Foreword to the P.A. (Tony) Lachenbruch, PhD
third edition:
Professor of Public Health, Oregon State Univ. Past President,
American Statistical Association Past President, International
Biometric Society Elected Member, International Statistics Institute

The third edition of Statistics in Medicine provides a wonderful pathway for people
to learn those methods (about 30% according to the author) used in 90% of all
(medical) statistical analyses. The message is clear: most statistical applications are con-
ducted with a relatively few procedures and these are all covered in this book.
 Acknowledgments

We consistently strive to develop, communicate, and apply statistical methodologies in

a pragmatic fashion in order to further progress science and public health. We are eter-
nally grateful to the many mentors, colleagues, and students that have helped us on
this journey.
We extend appreciation to all those acknowledged in prior editions. Although
many of you have moved on to new challenges, your contributions to this book con-
tinue to be recognized and appreciated.
We are grateful to Dr. Jessica Utts for writing the Foreword to this fourth edition.
Dr. Utts, some of whose stellar accomplishments are documented along with her
Foreword has long been a friend and esteemed colleague. We are also extremely
thankful to Michelle Nuño for carefully proofreading the text and providing valuable
feedback.
We are grateful to Stata Corporation for providing statistical software used in
much of the preparation of this book.
Finally, we thank our families for the patience and forbearance during our time of
neglect while preparing this edition.

xxi
 How to use this book?

1 GOALS
Purpose of the book
This book was written to teach and provide reference on statistical methods for research
workers in the medical sciences. The book starts at “ground zero” in mathematics and
statistics but assumes an intelligent, alert, and motivated student with ability in arith-
metic and a bit of algebra. It is designed to be offered without formal university-level
prerequisites.
The motivation for the book stems from our attempts to provide simple explana-
tions to statistically naïve collaborators. Thus its level and tone are designed to be
user-friendly to the health-care practitioner who does not engage in research on a reg-
ular basis. It was not written for statisticians, some of whom disapprove of its simplicity
relative to many traditional statistical texts. However, we believe this is a major factor
in its success.

The most used statistical methods and concepts are included

This book does not attempt to cover all biostatistical methods. Earlier editions of the
book referred to an article by Emerson and Colditz1 that analyzed the 301 articles
appearing in four volumes of NEJM for statistical content. The first two editions cov-
ered 90% of the statistical methods used in these 301 articles, the remaining 10% being
a scattering of infrequently used, often arcane methods. Since that time, more statistical
methods have come into common use and, correspondingly, more are covered in the
later editions.

Using a few data sets repeatedly allows the user to focus on the
method
The book opens with a number of databases having sample sizes small enough to be
given fully. These databases (DBs) are drawn from various medical areas, including
urology (DB1: prostate cancer), surgery (DB2: gall bladder removal), dermatology
(DB6: tattoo removal), orthopedics (DB7: femoral neck fractures), internal medicine
(DB11: treating malaria), ENT-HNS (DB12: carinal resection), pulmonary medicine
(DB14: bronchoconstriction), and others. Supplementary examples with larger sample
sizes from other medical fields are also included, summary statistics being provided for
the user. The database set is available online in MS Excel format in the Elsevier
website.

xxiii
xxiv How to use this book?

2 USE AS A TEXTBOOK VERSUS AS A REFERENCE

This book is intended to serve both as a text for a course in medical statistics and as a
reference to statistical methods for investigators. The first two editions started with 10
chapters for a course and 16 more for reference. It was found that the course part was
too long for some users and too short for others and that the investigator had to
maneuver back and forth for methods. As with the third edition, this fourth edition
begins from first concepts, adding new topics that are commonly encountered in med-
ical and public health research.
To use this edition for a course, chapters and sections can be selected according to
the recommendations appearing in Table 1.

Table 1 Suggested list of chapters/sections to constitute a course of indicated length.

Short course One-term course Year course

Immersion into 1 1 1
research
2 2 2
Basic tools and 3 3 3
concepts
4 4 4
5 5 5
6.1,2,3,4 6 6
7 7 7
8.1,3,5 8.1,2,3,4,5,6 8
Methods 9.1,2,3,4 9.1,2,3,4,6,7,8 9.1,2,3,4,5,6,7,8
10.1 10.1,2,3,4 10
11.1,2,3,6,7,8 11.1,2,3,4,6,7,8,10 11.1,2,3,4,6,7,8,10,11
12.1,2,3,4,5 12
14
15.1,2,3,7,8,9,11 15
16.1,2,3,4,5,6,7 16
17.1,2,3 17
19.1,2,3,4 18
19
21.1,2,3,4,5,6,7,10,11 20
22.1,2,3 21.1,2,3,4,5,6,7,10,11,13,14,17
23.1,2,3,4,5,10 22
25 23.1,2,3,4,5,10
24.1,2
25
26
Further topics As time As time permits As time permits
permits
 How to use this book? xxv

Students using this book are most often medical residents, fellows, and public
health students encountering their first exposure to research, but the material is suited
for all levels from premedical undergraduates to experienced staff by using minor
alterations in speed and depth of coverage and choice of material. We have been sur-
prised to learn that it has even been used successfully by high school students and by
advanced, experienced medical investigators.

3 POSSIBLE SCHEDULES FOR COURSES

Table 1 provides a list of chapters, or sections if chapters are not to be covered
completely, for three different lengths of course. Comments on the different lengths
of courses are given in adjoining paragraphs.
A large number of students will already have knowledge about some pieces of
Chapter 1, Planning Studies: From Design to Publication, and Chapter 2, Planning
Analysis: How to Reach My Scientific Objective, but most will be missing a piece
here and there. These chapters can be covered more quickly than the remainder of
the book but should at the very least be skimmed to fill in this or that element of
knowledge a particular student may be lacking. In general, the beginning chapters of
the book can be covered relatively quickly. The coverage should slow as the material
increases in complexity and reduces in familiarity.

Short course
Short courses on the recommended set of topics have been presented several times
each at Emory University School of Medicine, Rady Childrens’ Hospital San Diego,
and the Naval Medical Center San Diego. These courses were 10 clock hours equat-
ing to 12 50-minute university periods, consisting mainly of straight lecture with little
student interaction. (This is a description, not a recommendation.) There is not
enough time in such a course for a student to master more than the most rudimentary
statistical concepts and methods; the course exposes the student to the concepts, termi-
nology, and methods of statistics and assists the student’s ability to understand articles
in medical journals.
The recommended short course covers material from the first 11 chapters of the
text.

A three-credit semester course

A three-credit semester course includes 45 class periods, perhaps 42 lectures when
time for examinations is removed, equating to 35 60-minute hours, or about threefold
the time allowed for the short course. It includes material from additional nine chap-
ters or about 1.5 times the amount of material. Thus the semester course can proceed
xxvi How to use this book?

at a little slower rate than short course. The material can be studied in greater depth
with time for interaction between the students and the instructor.

A year course (six-semester credits)

A year course covers more material (all chapters with exception to 27 and 28) than
the one term course. It can proceed at about the rate of the one-term course for mate-
rial occurring in both course designs but allowing for greater time spent on the more
advanced material that will inevitably be more involved and less familiar.

REFERENCE
1. Emerson, J. D.; Colditz, G. A. Use of Statistical Analysis in the New England Journal of Medicine.
N Engl J Med 1983, 309 (12), 709 713.
 1

Planning studies: from design to

publication

(A few statistical terms commonly appearing in medical articles appear in this chapter without hav-
ing been previously defined. In case, a reader encounters an unfamiliar one, a glossary at the
chapter’s end provides interim definitions pending formal definitions later in this book.)

1.1 ORGANIZING A STUDY

A study must be organized sooner or later. Planning in advance from an overview
down to details increases efficiency, reduces false starts, reduces errors, and shortens
the time spent. By definition an impactful scientific study must be credible to the sci-
entific community. This implies that the study must meet minimal scientific standards,
including valid methods, valid measurements of study outcomes, valid quantification
of empirical results, and appropriate interpretations of study results. The most common
pitfalls of most studies stem from a lack of a priori design and planning. If that is not
enough motivation, the lazy and least stressful way to conduct a study, in the sense of
least work overall, is thorough planning upfront.

1.2 STAGES OF SCIENTIFIC INVESTIGATION

Stages
We gather data because we want to know something. These data are useful only if
they provide information about what we want to know. A scientist usually seeks to
develop knowledge in three stages. The first stage is to describe a class of scientific
events and formulate hypotheses regarding the nature of the events. The second stage
is to explain these events. The third stage is to predict the occurrence of these events.
The ability to predict an event implies some level of understanding of the rule of
nature governing the event. The ability to predict outcomes of actions allows the sci-
entist to make better decisions about such actions. At best, a general scientific rule
may be inferred from repeated events of this type. The latter two stages of a scientific

Statistics in Medicine r 2020 Elsevier Inc. 1

DOI: https://doi.org/10.1016/B978-0-12-815328-4.00001-2 All rights reserved.
2 CHAPTER 1 Planning studies: from design to publication

investigation will generally involve building a statistical model. A statistical model is an

abstract concept but in the most general of terms it is a mathematical model that is built
on a (generally) simplifying set of assumptions that attempts to explain the mechanistic
or data-generating process that gave rise to the data one has observed. In this way a sta-
tistical model allows one to infer from a sample to the larger population by relying
upon the assumptions made to describe the data-generating process. While the topic
may seem abstract, the reader has undoubtedly encountered and possibly utilized multi-
ple statistical models in practice. As an example, we might look at body mass index, or
BMI. BMI is an indicator of body weight adjusted for body size. The model is BMI
5 weight/height2, where weight is measured in kilograms and height in meters. (If
pounds and inches are used, the equation becomes BMI 5 703 3 weight/height2).
A 6-ft person (1.83 m) weighing 177 lb (80 kg) would have 80/1.832 5 23.9
BMI. To build such a model, we would start with weights and heights recorded for a
representative sample of normal people. (We will ignore underweight for this exam-
ple.) For a given height, there is an ideal weight and the greater the excess weight, the
lower the health. But ideal weight varies with body size. If we plot weights for various
heights, we find a curve that increases in slope as height increases, something akin to
the way y2 looks when plotted for x, so we try height2. For a fixed weight the body
mass measure goes down as height goes up, so the height term should be a divider of
weight, not a multiplier. Thus we have the BMI formula. Of course, many influences
are ignored to achieve simplicity. A better model would adjust for muscle mass, bone
density, and others, but such measures are hard to come by. Height and weight are
normally in every person’s medical history.
The model gives an estimate of, or approximation to, the body weight’s influence
on the person’s health. More generally, a model approximates a state or condition based on
measurements of influencing variables, whence its name, a model of the state, not a direct
measure. The greater the predictive accuracy and reliability of a model, the more
complicated the model needs to be. Usually, models are trade-offs between accessibil-
ity of measures and simplicity of interpretation versus the requirement for accuracy.
Sometimes it is necessary to formulate more complicated models in order to ensure
better predictive accuracy. For example, The American College of Cardiology utilizes
a model to estimate an individual’s 10-year risk of atherosclerotic cardiovascular disease
(ASCVD). This model utilizes 13 variables to obtain an estimate of the probability that
an individual will experience ASCVD within the next 10 years. These variables
include factors such as age, sex, weight, smoking status, systolic and diastolic blood
pressure, cholesterol levels, and medication use. The model then weights each of these
factors in order to compute an estimate of ASCVD risk. Due to the complexity of the
model, it is not easy to write down and communicate, as is the case with BMI.
Instead, it is easier to produce an “online calculator” that takes in each of the influenc-
ing variables and, behind the scenes, feeds these values into the model to report a final
 1.3 Science Underlying Clinical Decision-Making 3

estimate of the probability of ASCVD. As an example, the ASCVD online calculator

from The American College of Cardiology can be found at http://tools.acc.org/
ASCVD-Risk-Estimator-Plus.
Following is a brief explanation of the three stages of gathering knowledge.

THE CAUSATIVE PROCESS IS OF INTEREST, NOT THE DATA

A process, or set of forces, generates data related to an event. It is this process, not the
data per se, that interests us.
Description: The stage in which we seek to describe the data-generating process in
cases for which we have data from that process. Description would answer questions
such as: What is the range of prostate volumes for a sample of urology patients? What
is the difference in average volume between patients with negative biopsy results and
those with positive results?
Explanation: The stage in which we seek to infer characteristics of the (overall)
data-generating process when we have only part (usually a small part) of the possible
data. Inference would answer questions such as: Based on a sample of patients with
prostate problems, are the average volumes of patients with positive biopsy results less
than those of patients with negative biopsy results, for all men with prostate problems?
Such inferences usually take the form of tests of hypotheses.
Prediction: The stage in which we seek to make predictions about a characteristic of
the data-generating process on the basis of newly taken related observations. Such a
prediction would answer questions such as: On the basis of a patient’s negative digital
rectal examination, prostate-specific antigen of 9, and prostate volume of 30 mL, what
is the probability that he has prostate cancer? Such predictions allow us to make deci-
sions on how to treat our patients to change the chances of an event. For exam-
ple, should I perform a biopsy on my patient? Predictions usually take the form of a
mathematical model of the relationship between the predicted (dependent) variable
and the predictor (independent) variables.

1.3 SCIENCE UNDERLYING CLINICAL DECISION-MAKING

The scientific method
Science is a collection of fact and theory resting on information obtained by using a
particular method that is therefore called the scientific method. This method is a way
of obtaining information constrained by a set of criteria. The method is required to be
objective; the characteristics should be made explicit and mean the same to every user
of the information. The method should be unbiased, free of personal or corporate
agendas; the purpose is to investigate the truth and correctness of states and relation-
ships, not to “prove” them. The true scientific approach allows no preference for
4 CHAPTER 1 Planning studies: from design to publication

outcome. The method should involve the control of variables; ideally, it should elimi-
nate as far as practicable all sources of influence but one, so that the existence of and
extent of influence of that one source is undeniable. The method should be repeat-
able; other investigators should be able to repeat the experiment and come to the
same conclusion. The method should allow the accumulation of results; only by accu-
mulation does the information evolve from postulate to theory to fact. The scientific
method is the goal of good study design.

Jargon in science
Jargon may be defined as technical terminology or as pretentious language. The public
generally thinks of it as the latter. To the public, carcinoma is jargon for cancer, but to
the professional, technical connotation is required for scientific accuracy. We need to
differentiate between jargon for pomposity and jargon for accuracy, using it only for
the latter and not unnecessarily. The same process occurs in statistics. Some statistical
terms are used loosely and often erroneously by the public, who miss the technical
implications. Examples are randomness, independence, probability, and significance. Users of
statistics should be aware of the technical accuracy of statistical terms and use them
correctly.

Evidence
The accumulating information resulting from medical studies is evidence. Some types
of studies yield more credible evidence than others. Anecdotal evidence, often dis-
missed by users seeking scientific information, is the least credible, yet is still evidence.
The anecdotal information that patients with a particular disease often improve more
quickly than usual when taking a certain herb may give the rate of improvement but
not the rate of failure of the treatment. It may serve as a candle in a dark room.
However, such evidence may suggest that a credible study be done. The quality of the
study improves as we pass through registries, case control studies, and cohort studies,
to the current gold standard of credibility, the randomized controlled prospective clin-
ical trial (RCT). (See Sections 1.5 and 1.6 for more information on types of studies.)
It is incumbent on the user of evidence to evaluate the credibility of the cumulative
evidence: number of accumulated studies, types of studies, quality of control over
influencing factors, sample sizes, and peer reviews. Evidence may be thought of as the
blocks that are combined to build the scientific edifice of theory and fact. The more
solid blocks should form the cornerstones and some blocks might well be rejected.

Evidence versus proof

The results of a single study are seldom conclusive. We seldom see true absolute proof
in science. As evidence accrues from similar investigations, confidence increases in the
 1.4 Why Do We Need Statistics? 5

correctness of the answer. The news media like to say, “The jury is still out.” In a
more accurate rendition of that analogy, the jurors come in and lodge their judgment
one at a time—with no set number of jurors.

Evidence-based medicine
Evidence-based medicine (EBM) melds the art and science of medicine. EBM is just
the ideal paradigm of health-care practice, with the added requirement that updated
credible evidence associated with treatment be sought, found, assessed, and incorpo-
rated into practice. It is much the way we all think we practice, but it ensures consid-
eration of the evidence components. It could be looked at somewhat like an airliner
cockpit check; even though we usually mentally tick off all the items, formal guides
verify that we have not overlooked something.
One rendition of the EBM sequence might be the following: (1) we acquire the
evidence: the patient’s medical history, the clinical picture, test results, and relevant
published studies. (2) We update, assess, and evaluate the evidence, eliminating evi-
dence that is not credible, weighting that remaining evidence according to its credibil-
ity, and prioritizing that remaining according to its relevance to the case at hand. (3)
We integrate the evidence of different types and from different sources. (4) We add
nonmedical aspects, for example, cost considerations, the likelihood of patient cooper-
ation, and the likelihood of patient follow-up. (5) Finally, we embed the integrated
totality of evidence into a decision model.

1.4 WHY DO WE NEED STATISTICS?

Primary objective
A primary objective of statistics is to make an inference about a population based on a
sample from that population.

Population versus sample

The term population refers to all members of a defined group and the term sample to a
subset of the population. As an example, patients in a hospital would constitute the
entire population for a study of infection control in that hospital. However, for a study
of infected patients in the nation’s hospitals, the same group of patients would be but
a tiny sample. The same group can be a sample for one question about its characteris-
tics and a population for another question.

Objective restated
In the context of inferring a treatment effect, the symbol α is assigned to the chance of
concluding that a treatment difference exists when in fact it does not (otherwise known
as a type I error in statistical terms). We may restate this common objective of statistics
6 CHAPTER 1 Planning studies: from design to publication

as follows: based on a sample, we wish to bound the chance of concluding that a treat-
ment difference exists in the population when it truly does not (a false-positive differ-
ence) by an agreed upon α. For example, of 50 urgent care patients with dyspepsia
who are given no treatment, 30 are better within an hour and of 50 given a “GI cock-
tail” (antacid with viscous lidocaine), 36 are better within an hour. In order to decide if
the treatment is effective in the population based on this sample, in that the condition
of 20% more treated than untreated patients showed improvement for these 100
patients, we calculate the probability that an improvement of this magnitude (or more)
would have been observed by chance if the treatment had no effect. The question for
statistics to answer is: Is it likely to work in the overall population of urgent care
patients with dyspepsia, or was the result for this sample “luck of the draw”?

What statistics will not do for us

Statistics will not make uncertainty disappear. Statistics will not automatically formu-
late a scientific hypothesis. Statistics will not give answers without thought and effort.
Statistics will not provide a credible conclusion from poor data, that is, to use an old
maxim, it will not make a silk purse out of a sow’s ear. It is worth keeping in mind
that putting numbers into a formula will yield an answer but the process will not inform
the user whether the answer is credible. The onus is on the user researcher to apply
credible data in a credible manner to obtain a credible answer.

What statistics will do for us

There is no remedy for uncertainty, but statistics allows you to measure, quantify, and
account for uncertainty, and in many cases to reduce uncertainty through study design that is
founded on statistical principles. This benefit is one of the most crucial and critically
important bases for scientific investigation. In addition, statistics and statistical thinking
can assist us to do the following:
• Refine and clarify our exact question.
• Identify the variable and the measure of that variable that will answer that question.
• Verify that the planned sample size is adequate.
• Test our sample to see if it adequately represents the population.
• Answer the question asked, while limiting bounding the risk for error in our
decision.
Other benefits of statistics include the following:
• allowing us to follow strands of evidence obscured by myriad causes,
• allowing us to mine unforeseen knowledge from a mountain of data in order to
generate new hypotheses,
• providing the credibility for the evidence required in EBM, and
• reducing the frequency of embarrassing mistakes in medical research.
 1.5 Concepts in Study Design 7

1.5 CONCEPTS IN STUDY DESIGN

Components of a study
A medical clinical study is an experiment or gathering of data in a designed fashion in
order to answer a specific question about a population of patients. A study design may
be involved, approaching the arcane. Breaking it into the components used in con-
structing a study will simplify it. The basic steps are as follows:
• Specify, clearly and unequivocally, a question to be answered about an explicitly
defined population.
• Identify a measurable variable capable of answering the question.
• Obtain observations on this variable from a sample that represents the population.
• Analyze the data with methods that provide a valid answer to the question.
• Generalize this answer to the population, limiting the generalization by the mea-
sured probability of being correct.

Control groups and placebos

A frequent mechanism to pinpoint the effect of a treatment and to reduce bias is
to provide a control group having all the characteristics of the experimental group
except the treatment under study. For example, in an animal experiment on the
removal of a generated tumor, the control animals would be surgically opened
and closed without removing the tumor, so that the surgery itself will not influ-
ence the effect of removing the tumor. In the case of a drug efficacy study, a
control group may be provided by introducing a placebo, a capsule appearing (and
possibly feeling) identical to that being given to the experimental group but lack-
ing the study drug.

Variables
A variable is just a term for an observation or reading giving information on the study
question to be answered. Blood pressure is a variable giving information on hyperten-
sion. Blood uric acid level is a variable giving information on gout. The term variable
may also refer to the symbol denoting this observation or reading.
In study design, it is essential to differentiate between independent and dependent
variables. Let us define these terms.
An independent variable is a variable that, for the purposes of the study question to
be answered, occurs independently of the effects being studied. A dependent variable is
a variable that depends on, or more exactly is influenced by, the independent variable.
In a study on gout, suppose we ask if blood uric acid (level) is a factor in causing pain.
We record blood uric acid level as a measurable variable that occurs in the patient.
Then we record pain as reported by the patient. We believe blood uric acid level is
predictive of pain. In this relationship, the blood uric acid is the independent variable
Another random document with
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praise God, with a loud voice, for all the mighty works that they had
seen; saying, “Blessed be the King of Israel, that cometh in the
name of the Lord! Peace in heaven! Glory in the highest! Blessed be
the kingdom of our father David! Hosanna!” These acclamations
were raised by the disciples, and heartily joined in by the multitudes
who knew his wonderful works, and more especially those who were
acquainted with the very recent miracle of raising Lazarus. A great
sensation of wonder was created throughout the city, by such a burst
of shouts from a multitude, sweeping in a long, imposing train, with
palm branches in their hands, down the mountain, on which they
could have been seen all over Jerusalem. As he entered the gates,
all the city was moved to say, “Who is this?” And the rejoicing
multitude said, “This is Jesus, the prophet of Nazareth in Galilee.”
What scorn did not this reply awaken in many of the haughty
aristocrats of Jerusalem, to learn that all this solemn parade had
been got up for no better purpose than merely to honor a dweller of
that outcast region of mongrels, Galilee! And of all places, that this
prophet, so called, should have come from Nazareth! A prophet from
Galilee, indeed! Was it from this half-heathen district, that the
favored inhabitants of the capital of Judaism were to receive a
teacher of religion? Were the strict faith, and the rigid observances of
their learned and devout, to be displaced by the presumptuous
reformations of a self-taught prophet, from such a country? Swelling
with these feelings, the Pharisees could not repress a remonstrance
with Jesus, against these noisy proceedings. But he, evidently
affected with pleasure at the honest tribute thus wrung out in spite of
sectional feeling, forcibly asserted the propriety and justice of this
free offering of praise. “I tell you, that if these should hold their
peace, the stones would immediately cry out.”

With palm-branches in their hands.――This tree, the emblem of joy and triumph in every
part of the world where it is known, was the more readily adopted on this occasion, by those
who thronged to swell the triumphal train of Jesus of Nazareth, because the palm grew
along the way-side where they passed, and the whole mount was hardly less rich in this
than in the far famed olive from which it drew its name. A proof of the abundance of the
palm-trees on Olivet is found in the name of the village of Bethany, ‫בית חיני‬, (beth-hene,)
“house of dates,” which shows that the tree which bore this fruit must have been plentiful
there. The people, as they passed on with Jesus from this village whence he started to
enter the city, would therefore find this token of triumph hanging over their heads, and
shading their path every where within reach, and the emotions of joy at their approach to
the city of God in the company of this good and mighty prophet, prompted them at once to
use the expressive emblems which hung so near at hand; and which were alike within the
reach of those who journeyed with Jesus, and those who came forth from the city to meet
and escort him in. The presence of these triumphal signs would, of course, remind them at
once of the feast of the tabernacles, the day on which, in obedience to the Mosaic statute,
all the dwellers of the city were accustomed to go forth to the mount, and bring home these
branches with songs of joy. (Leviticus xxiii. 40, Nehemiah viii. 15, 16.) The remembrance of
this festival at once recalled also the beautifully appropriate words of the noble national and
religious hymn, which they always chanted in praise of the God of their fathers on that day,
(see Kuinoel, Rosenmueller, Wolf, &c.) and which was so peculiarly applicable to him who
now “came in the name of the Lord,” to honor and to bless his people. (Psalm cxviii. 26.)

The descent of the Mount of Olives.――To imagine this scene, with something of the
force of reality, it must be remembered that the Mount of Olives, so often mentioned in the
scenes of Christ’s life, rose on the eastern side of Jerusalem beyond the valley of the
Kedron, whose little stream flowed between this mountain and Mount Moriah, on which the
temple stood. Mount Olivet was much higher than any part of the city within the walls, and
the most commanding and satisfactory view of the holy city which modern travelers and
draughtsmen have been able to present to us in a picture, is that from the more than classic
summit of this mountain. The great northern road passing through Jericho, approaches
Jerusalem on its north-eastern side, and comes directly over the top of Olivet, and as it
mounts the ridge, it brings the holy city in all its glory, directly on the traveler’s view.

Hosanna.――This also is an expression taken from the same festal hymn, (Psalm cxviii.
25,) ‫( הושיעה־נא‬hoshia-na) a pure Hebrew expression, as Drusius shows, and not Syriac,
(See Poole’s Synopsis on Matthew xxi. 9,) but corrupted in the vulgar pronunciation of this
frequently repeated hymn, into Hosanna. The meaning of the Hebrew is “save him” or “be
gracious to him,” that is in connection with the words which follow in the gospel story, “Be
gracious, O Lord, to the son of David.” This is the same Hebrew phrase which, in the psalm
above quoted, (verse 25,) is translated “Save now.” The whole expression was somewhat
like the English “God save the king,” in its import.

Nazareth.――This city, in particular, had an odious name, for the general low character
of its inhabitants. The passage in John i. 46, shows in what estimation this city and its
inhabitants were held, by their own neighbors in Galilee; and the great scorn with which all
Galileans were regarded by the Jews, must have redoubled their contempt of this poor
village, so despised even by the despicable. The consequence was that the Nazarenes
acquired so low a character, that the name became a sort of byword for what was mean and
foolish. (See Kuinoel on Matthew ii. 23, John i. 46. Also Rosenmueller on the former
passage and Bloomfield on the latter.)

Galilee.――In order to appreciate fully, the scorn and suspicion with which the Galileans
were regarded by the citizens of Jerusalem, a complete view of their sectional peculiarities
would be necessary. Such a view will hereafter be given in connection with a passage which
more directly refers to those peculiarities, and more especially requires illustration and
explanation.

the blighting of the fig-tree.

 Having thus, by his public and triumphant entrance into
Jerusalem, defied and provoked the spite of the higher orders, while
he secured an attentive hearing from the common people, when he
should wish to teach them,――Jesus retired at evening, for the sake
of quiet and comfort, to the house of his friends, Lazarus, Mary and
Martha, at Bethany, in the suburbs. The next morning, as he was on
his way with his disciples, coming back from this place to Jerusalem,
hungry with the fatigues of his long walk, he came to a fig-tree, near
the path, hoping to find fruit for his refreshment, as it seemed from a
distance flourishing with abundance of leaves, and was then near
the season of bearing. But when he came near, he found nothing but
leaves on it, for it was somewhat backward, and its time of producing
figs was not yet. And Jesus, seizing the opportunity of this
disappointment to impress his disciples with his power, personifying
the tree, denounced destruction against it. “May no man eat fruit of
thee hereafter, forever.” And his disciples heard it. They returned to
Bethany, as usual, that evening, to pass the night,――but as they
passed, probably after dark, they took no notice of the fig-tree. But
the next morning, as they went back to the city, they saw that it had
dried up from the roots. Simon Peter, always ready to notice the
instances of his Master’s power, called out in surprise to Jesus, to
witness the effect of his malediction upon its object. “Master, behold,
the fig-tree which thou didst curse, is withered away.” Jesus noticing
their amazement at the apparent effect of his words, in so small a
matter, took occasion to turn their attention to other and higher
objects of faith, on which they might exert their zeal in a spirit, not of
withering denunciation and destroying wrath, such as they had seen
so tremendously efficient in this case, but in the spirit of love and
forgiveness, as well as of the holy energy that could overthrow and
overcome difficulties, not less than to uproot Mount Olivet from its
everlasting base and hurl it into the sea.

the discussions with the sectaries.

The disciples steadily remained the diligent and constant

attendants of their heavenly teacher, in his long and frequent
seasons of instruction in the temple, where he boldly met the often
renewed attacks of his various adversaries, whether Herodians,
scribes, Pharisees or Sadducees, and in spite of their long-trained
subtleties, beat them out and out, with the very weapons at which
they thought themselves so handy. The display of genius, of taste, of
learning, of ready and sarcastic wit, and of heart-searching
acuteness, was so amazing and super-human, that these few days
of open discussion established his divinely intellectual superiority
over all the elaborate science of his accomplished opponents, and at
the same time secured the fulfilment of his destiny, by the spite and
hatred which their repeated public defeats excited in them. Imagine
their rage. Exposed thus before the people, by whom they had
hitherto been regarded as the sole depositaries of learning, and
adored as the fountains of right, they saw all their honors and power,
to which they had devoted the intense study of their whole lives,
snatched coolly and easily from them, by a nameless, untaught
pretender, who was able to hold them up, baffled and disgraced, for
the amusement of the jeering multitude. Here was ground enough for
hatred;――the hatred of conceited and intolerant false learning,
against the discerning soul that had stripped and humbled it;――the
hatred of confident ambition against the heroic energy which had
discomfited it, and was doing much to free a long enslaved people
from the yoke which formal hypocrisy and empty parade had long
laid on them. And again, the intolerable thought that all this heavy
disgrace had been brought on the learned body of Judaism by a
Galilean! a mere carpenter of the lowest orders, who had come up to
Jerusalem followed by a select train of rude fishermen and outcast
publicans;――and who, not being able to command a single night’s
lodging in the city, was in the habit of boarding and lodging in a paltry
suburb, on the charity of some personal friends, from which place he
quietly walked in for the distance of two miles every morning, to
triumph over the palace-lodged heads of the Jewish faith. From such
a man, thus humbly and even pitiably circumstanced, such an
invasion and overthrow could not be endured; and his ruin was
rendered doubly easy by his very insignificance, which now
constituted the chief disgrace of their defeat. Never was cause more
closely followed by its effect, than this insulted dignity was by its
cruel vengeance.

the prophecy of the temple’s ruin.

In preparing his disciples for the great events which were to take
place in a few years, and which were to have a great influence on
their labors, Jesus foretold to them the destruction of the temple. As
he was passing out through the mighty gates of the temple on some
occasion with his disciples, one of them, admiring the gorgeous
beauty of the architecture and the materials, with all the devotion of a
Jew now visiting it for the first time, said to him, “Master, see! what
stones and what buildings!” To him, Jesus replied with the awful
prophecy, most shocking to the national pride and religious
associations of every Israelite,――that ere long, upon that glorious
pile should fall a ruin so complete, that not one of those splendid
stones should be left upon another. These words must have made a
strong impression of wonder on all who heard them; but no farther
details of the prophecy were given to the disciples at large. Not long
afterwards, however, as he sat musingly by himself, in his favorite
retirement, half-way up the Mount of Olives, over against the temple,
the four most loved and honored of the twelve, Peter, James, John
and Andrew, came to him, and asked him privately, to tell them when
these things should be, and by what omen they should know the
approach of the great and woful ruin. Sitting there, they had a full
view of the enormous pile which rose in immense masses very near
them, on the verge of mount Moriah, and was even terraced up, from
the side of the slope, presenting a vast wall, rising from the depths of
the deep ravine of Kedron, which separated the temple from mount
Olivet, where they were. It was morning when the conversation took
place, as we may fairly guess, for this spot lay on the daily walk to
Bethany, where he lodged;――the broad walls, high towers, and
pillars of the temple, were doubtless illuminated by the full splendors
of the morning sun of Palestine; for Olivet was directly east of
Jerusalem, and as they sat looking westward towards the temple,
with the sun behind them, the rays, leaving their faces in the shade,
would shine full and bright on all which crowned the highth beyond. It
was at such a time, as the Jewish historian assures us, that the
temple was seen in its fullest grandeur and sublimity; for the light,
falling on the vast roofs, which were sheeted and spiked with pure
gold, brightly polished, and upon the turrets and pinnacles which
glittered with the same precious metal, was reflected to the eye of
the gazer with an insupportable brilliancy, from the million bright
surfaces and shining points which covered it. Here, then, sat Jesus
and his four adoring chosen ones, with this splendid sight before
them crowning the mountain, now made doubly dazzling by contrast
with the deep gloom of the dark glen below, which separated them
from it. There it was, that, with all this brightness and glory and
beauty before them, Jesus solemnly foretold in detail the awful, total
ruin which was to sweep it all away, within the short lives of those
who heard him. Well might such words sink deep into their
hearts,――words coming from lips whose perfect and divine truth
they could not doubt, though the things now foretold must have gone
wofully against all the dreams of glory, in which they had made that
sacred pile the scene of the future triumphs of the faith and followers
of Christ. This sublime prophecy, which need not here be repeated
or descanted upon, is given at great length by all the first three
evangelists, and is found in Matthew xxiv. Mark xiii. and Luke xxi.

The view of the temple.――I can find no description by any writer, ancient or modern,
which gives so clear an account of the original shape of Mount Moriah, and of the
modifications it underwent to fit it to support the temple, as that given by Josephus. (Jewish
War, book V. chapter v.) In speaking of the original founding of the temple by Solomon,
(Antiquities book VIII. chapter iii. section 2,) he says, “The king laid the foundations of the
temple in the very depths, (at the bottom of the descent,) using stones of a firm structure,
and able to hold out against the attacks of time, so that growing into a union, as it were, with
the ground, they might be the basis and support of the pile that was to be reared above, and
through their strength below, easily bear the vast mass of the great superstructure, and the
immense weight of ornament also; for the weight of those things which were contrived for
beauty and magnificence was not less than that of the materials which contributed to the
highth and lateral dimension.” In the full description which he afterwards gives in the place
first quoted, of the later temple as perfected by Herod, which is the building to which the
account in the text refers, he enters more fully into the mode of shaping the ground to the
temple. “The temple was founded upon a steep hill, but in the first beginning of the structure
there was scarcely flat ground enough on the top for the sanctuary and the altar, for it was
abrupt and precipitous all around. And king Solomon, when he built the sanctuary, having
walled it out on the eastern side, (εκτειχισαντος, that is, ‘having built out a wall on that side’
for a terrace,) then reared upon the terraced earth a colonnade; but on the other sides the
sanctuary was naked,――(that is, the wall was unsupported and unornamented by
colonnades as it was on the east.) But in the course of ages, the people all the while
beating down the terraced earth with their footsteps, the hill thus growing flat, was made
broader on the top; and having taken down the wall on the north, they gained considerable
ground which was afterwards inclosed within the outer court of the temple. Finally, having
walled the hill entirely around with three terraces, and having advanced the work far beyond
any hope that could have been reasonably entertained at first, spending on it long ages,
and all the sacred treasures accumulated from the offerings sent to God from the ends of
the world, they reared around it, both the upper courts and the lower temple, walling the
latter up, in the lowest part, from a depth of three hundred cubits, (450 feet,) and in some
places more. And yet the whole depth of the foundations did not show itself, because they
had greatly filled up the ravines, with a view to bring them to a level with the streets of the
city. The stones of this work were of the size of forty cubits, (60 feet,) for the profusion of
means and the lavish zeal of the people advanced the improvements of the temple beyond
account; and a perfection far above all hope was thus attained by perseverance and time.

“And well worthy of these foundations were the works which stood upon them. For all the
colonnades were double, consisting of pillars twenty-five cubits (40 feet) in highth, each of a
single stone of the whitest marble, and were roofed with fretwork of cedar. The natural
beauty of these, their high polish and exquisite proportion, presented a most glorious show;
but their surface was not marked by the superfluous embellishments of painting and
carving. The colonnades were thirty cubits broad, (that is, forty-five feet from the front of the
columns to the wall behind them;) while their whole circuit embraced a range of six stadia,
(more than three-quarters of a mile!) including the castle of Antonia. And the whole
hypethrum (ὑπαιθρον, the floor of the courts or inclosures of the temple, which was exposed
to the open air, there being no roof above it) was variegated by the stones of all colors with
which it was laid,” (making a Mosaic pavement.) Section 1.

“The outside of the temple too, lacked nothing that could strike or dazzle the mind and
eye. For it was on all sides overlaid with massy plates of gold, so that in the first light of the
rising sun, it shot forth a most fiery splendor, which turned away the eyes of those
who compelled themselves (mid. βιαζομενους) to gaze on it, as from the rays of the sun
itself. To strangers, moreover, who were coming towards it, it shone from afar like a
complete mountain of snow: for where it was not covered with gold it was most dazzlingly
white, and above on the roof it had golden spikes, sharpened to keep the birds from lighting
on it. And some of the stones of the building were forty-five cubits long, five high, and six
broad;”――(or sixty-seven feet long, seven and a half high, and nine broad.) Section 6.

“The Antonia was placed at the angle made by the meeting of two colonnades of the
outer temple, the western and the northern. It was built upon a rock, fifty cubits high, and
precipitous on all sides. It was the work of king Herod, in which, most of all, he showed
himself a man of exalted conceptions.” Section 8.

In speaking of Solomon’s foundation, he also says, (Antiquities book VIII. chapter iii.
section 9,)

“But he made the outside of the temple wonderful beyond account, both in description
and to sight. For having piled up huge terraces, from which, on account of their immense
depth, it was hardly possible to look down, and reared them to the highth of four hundred
cubits, (six hundred feet!) he made them on the same level with the hill’s top on which the
shrine (ναος) was built, and thus the open floor of the temple (ἱερον, or the outer court’s
inclosure) was level with the shrine.”

I have drawn thus largely from the rich descriptions of this noble and faithful describer of
the old glories of the Holy Land, because this very literal translation gives the exact naked
detail of the temple’s aspect, in language as gorgeous as the most high-wrought in which it
could be presented in a mere fancy picture of the same scene; and because it will prove
that my conception of its glory, as it appeared to Christ and the four disciples who “sat over
against it upon the Mount of Olives,” is not overdrawn, since it is thus supported by the
blameless and invaluable testimony of him who saw all this splendor in its most splendid
day, and afterwards in its unequaled beauty and with all its polished gold and marble,
shining and sinking amid the flames, which swept it utterly away from his saddening eyes
forever, to a ruin the most absolute and irretrievable that ever fell upon the works of man.

This was the temple on which the sons of Jonah and Zebedee gazed, with the awful
denunciation of its utter ruin falling from their Lord’s lips, and such was the desolation to
which those terrible words devoted it. This full description of its location shows the manner
in which its terraced foundations descended with their vast fronts, six hundred feet into the
valley of Kedron, over which they looked. To give as clear an idea of the place where they
sat, and its relations to the rest of the scene, I extract from Conder’s Modern Traveler the
following description of Mount Olivet.

“The Mount of Olives forms part of a ridge of limestone hills, extending to the north and
the south-west. Pococke describes it as having four summits. On the lowest and most
northerly of these, which, he tells us, is called Sulman Tashy, the stone of Solomon, there is
a large domed sepulcher, and several other Mohammedan tombs. The ascent to this point,
which is to the north-east of the city, he describes as very gradual, through pleasant corn-
fields planted with olive-trees. The second summit is that which overlooks the city: the path
to it rises from the ruined gardens of Gethsemane, which occupy part of the valley. About
half way up the ascent is a ruined monastery, built, as the monks tell us, on the spot where
the Savior wept over Jerusalem. From this point the spectator enjoys, perhaps, the best
view of the Holy City. (Here Jesus sat, in our scene.)

“The valley of Jehoshaphat, which lies between this mountain and the hills on which
Jerusalem is built, is still used as a burial-place by the modern Jews, as it was by their
ancestors. It is, generally speaking, a rocky flat, with a few patches of earth here and there,
about half a mile in breadth from the Kedron to the foot of Mount Olivet, and nearly of the
same length from Siloa to the garden of Gethsemane. The Jews have a tradition, evidently
founded on taking literally the passage Joel iii. 12, that this narrow valley will be the scene
of the final judgment. The prophet Jeremiah evidently refers to the same valley under the
name of the valley of the Son of Hinnom, or the valley of Tophet, the situation being clearly
marked as being by the entry of the east gate. (Jeremiah xix. 2, 6.) Pococke places the
valley of Hinnom to the south of Jerusalem, but thinks it might include part of that to the
east. It formed part of the bounds between the tribes of Benjamin and Judah, (Joshua xv. 8.
xviii. 16,) but the description is somewhat obscure.” [Modern Traveler Palestine, pp. 168,
172.]
 MOUNT MORIAH.

the last supper.

Meanwhile the offended and provoked dignitaries of Judaism were

fast making arrangements to crush the daring innovator, who had
done so much to bring their learning and their power into contempt.
Some of the most fiery spirits among them, were for defying all risks,
by seizing the Nazarene openly, in the midst of his audacious
denunciations of the higher orders; and the attempt was made to
execute this act of arbitrary power; but the mere hirelings sent upon
the errand, were too much awed by the unequaled majesty of the
man, and by the strong attachment of the people to him, to be willing
to execute their commission. But there were old heads among them,
that could contrive safer and surer ways of meeting the evil. By them
it was finally determined to seize Jesus when alone or unattended by
the throngs which usually encompassed him,――to hurry him at
once secretly through the forms of law necessary for his
commitment, and then to put him immediately into the hands of the
Roman governor, as a condemned rioter and rebel, who would be
obliged to order his execution in such a way as that no popular
excitement would rescue the victim from the grasp of the soldiery.
This was the plan which they were now arranging, and which they
were prepared to execute before the close of the passover, if they
could get intelligence of his motions. These fatal schemes of hate
could not have been unknown to Jesus; yet the knowledge of them
made no difference in his bold devotion to the cause for which he
came into the world. Anxious to improve the few fast fleeting hours
that remained before the time of his sufferings should come on, and
desirous to join as a Jew in this great national festival, by keeping it
in form with his disciples, he directed his two most confidential
apostles, Peter and John, to get ready the entertainment for them in
the city, by an arrangement made with a man already expecting to
receive them. This commission they faithfully executed, and Jesus
accordingly ate with his disciples the feast of the first day of the
passover, in Jerusalem, with those who sought his life so near him.
After the supper was over, he determined to use the brief remnant of
time for the purpose of uprooting that low feeling of jealous ambition
which had already made so much trouble among them, in their
anxious discussions as to who should be accounted the greatest,
and should rank as the ruler of the twelve. To impress the right view
upon their minds most effectually, he chose the oriental mode of a
ceremony which should strike their senses, and thus secure a regard
and remembrance for his words which they might fail in attaining if
they were delivered in the simple manner of trite and oft spoken oral
truisms. He therefore rose after supper, and leaving his place at the
head of the table, he laid aside his upper garments, which, though
appropriate and becoming him as a teacher in his hours of public
instruction, or social communion, were yet inconvenient in any active
exertion which needed the free use of the limbs. Being thus
disrobed, he took the position and character of a menial upon him,
and girding himself with a towel, he poured water into a basin and
began to wash the disciples’ feet in it, wiping them with his towel. He
accordingly comes to Simon Peter, in the discharge of his servile
office; but Peter, whose ideas of the majesty and ripening honors of
his Master were shocked at this extraordinary action, positively
refused to be even the passive instrument of such an indignity to one
so great and good,――first inquiring “Lord, dost thou wash my feet?”
Jesus in answer said to him, “What I do, thou knowest not now, but
thou shalt know hereafter.” That is, “this apparently degrading act
has a hidden, useful meaning, at this moment beyond your
comprehension, but which you will learn in due time.” Peter,
however, notwithstanding this plain and decided expression of
Christ’s wise determination to go through this painful ceremony, for
the instruction of those who so unwillingly submitted to see him thus
degraded,――still led on by the fiery ardor of his own headlong
genius,――manfully persisted in his refusal, and expressed himself
in the most positive terms possible, saying to Jesus, “Thou shalt
never wash my feet.” Jesus answered, “If I wash thee not, thou hast
no part with me.” This solemn remonstrance had the effect of
checking Peter’s too forward reverence, and in a tone of deeper
submission to the wise will of his Master, he yielded, replying
however, “Lord, wash not my feet only, but also my hands and my
head.” Since so low an office was to be performed by one so
venerated, he would not have the favor of his blessed touch confined
to the baser limbs, but desired that the nobler parts of the body
should share in the holy ablution. But the high purpose of Jesus
could not accommodate itself to the whims of his zealous disciple;
for his very object was to take the humblest attitude before them, by
performing those personal offices which were usually committed to
slaves. He therefore told Peter, “He that is washed needs not save to
wash his feet, but is clean in every part;”――a very familiar and
expressive illustration, alluding to the circumstance that those who
have been to a bath and there washed themselves, will on their
return find themselves wholly clean, except such dust as may cling
to their feet as they have passed through the streets on their return.
And any one may feel the force of the beautiful figure, who has ever
gone into the water for the purposes of cleanliness and refreshment,
on a warm summer’s day in this country, and has found by
experience that after all possible ablution, on coming out and
dressing himself, his wet feet in contact with the ground have
become loaded with dirt which demands new diligence to remove it;
and as all who have tried it know, it requires many ingenious efforts
to return with feet as clean as they came to the washing; and in spite
of all, after the return, an inspection may forcibly illustrate the truth,
that “he that is washed, though he is clean in every part, yet needs to
wash his feet.” Such was the figure with which Jesus expressed to
his simple-minded and unlettered disciples, the important truth, that
since they had been already washed, (baptized by John or himself,)
if that washing had been effectual, they could need the repurification
only of their feet――the cleansing away of such of the world’s
impure thoughts and feelings as had clung to them in their
journeyings through it. So, after he had washed their feet, and had
taken his garments and sat down again, he said to them, “Know ye
what I have done to you? Ye call me Master and Lord; and ye say
well, for so I am. If I then, your Lord and Master, have washed your
feet, ye also ought to wash one another’s feet. For I have given you
this as an example, that ye should do as I have done to you. Truly
the servant is not greater than his lord, neither is he that is sent
greater than him that sent him. If ye know these things, happy are ye
if ye do them.”――A charge so clear and simple, and so full, that it
needs not a word of comment to show any reader the full force of
this touching ceremony.

Shortly after, in the same place and during the same meeting,
Jesus speaking to them of his near departure, affectionately and
sadly said, “Little children, but a little while longer am I with you. Ye
shall seek me; and as I said to the Jews, ‘whither I go, ye cannot
come,’――so now I say to you.” To this Simon Peter soon after
replied by asking him, “Lord whither goest thou?” Jesus answered
him, “Whither I go thou canst not follow me now, but thou shalt follow
me afterwards.” Peter, perhaps beginning to perceive the mournful
meaning of this declaration, replied, still urging, “Lord, why cannot I
follow thee now? I will lay down my life for thy sake.” Jesus
answered, “Wilt thou lay down thy life for my sake? I tell thee
assuredly, the cock shall not crow till thou hast denied me
thrice.”――Soon after, at the same time and place, noticing the
confident assurance of this chief disciple, Jesus again warned him of
his danger and his coming fall. “Simon! Simon! behold, Satan has
desired to have you (all) that he may sift you as wheat; but I have
prayed for thee (especially) that thy faith fail not; and when thou art
converted, strengthen thy brethren.” Never before had higher and
more distinctive favor been conferred on this chief apostle, than by
this sad prophecy of danger, weakness and sin, on which he was to
fall, for a time, to his deep disgrace; but on him alone, when rescued
from ruin by his Master’s peculiar prayers, was to rest the task of
strengthening his brethren. But his Master’s kind warning was for the
present lost on his immovable self-esteem; he repeated his former
assurance of perfect devotion through every danger, “Lord, I am
ready to go with thee into prison and to death.” Where was
affectionate and heroic devotion ever more affectingly and
determinedly expressed? What heart of common man would not
have leaped to meet such love and fidelity? But He, with an eye still
clear and piercing, in spite of the tears with which affection might dim
it, saw through the veil that would have blinded the sharpest human
judgment, and coldly met these protestations of burning zeal with the
chilling prediction again uttered, “I tell thee, Peter, the cock shall not
crow this day, before thou shalt thrice deny that thou knowest me.”
Then making a sudden transition, to hint to them the nature of the
dangers which would soon try their souls, he suddenly reverted to
their former security. “When I sent you forth without purse, or scrip,
or shoes, did ye need any thing?” And they said “Nothing.” Then said
he to them “But now, let him that has a purse, take it, and likewise
his scrip; and let him that has no sword sell his cloak and buy one.”
They had hitherto, in their wanderings, every where found friends to
support and protect them; but now the world was at war with them,
and they must look to their own resources both for supplying their
wants and guarding their lives. His disciples readily apprehending
some need of personal defense, at once bestirred themselves and
mustered what arms they could on the spot, and told him that they
had two swords among them, and of these it appears that one was in
the hands of Peter. It was natural enough that among the disciples
these few arms were found, for they were all Galileans, who, as
Josephus tells us, were very pugnacious in their habits; and even the
followers of Christ, notwithstanding their peaceful calling, had not
entirely laid aside their former weapons of violence, which were the
more needed by them, as the journey from Galilee to Jerusalem was
made very dangerous by robbers, who lay in wait for the defenseless
traveler wherever the nature of the ground favored such an attack.
Of this character was that part of the road between Jerusalem and
Jericho, alluded to in the parable of the wounded traveler and the
good Samaritan,――a region so wild and rocky that it has always
been dangerous, for the same reasons, even to this day; of which a
sad instance occurred but a few years ago, in the case of an eminent
English traveler, who going down from Jerusalem to Jericho, fell
among thieves and was wounded near the same spot mentioned by
Christ, in spite of the defenses with which he was provided. It was in
reference to such dangers as these, that two of his disciples had
provided themselves with hostile weapons, and Peter may have
been instigated to carry his sword into such a peaceful feast, by the
suspicion that the danger from the chief priests, to which Christ had
often alluded, might more particularly threaten them while they were
in the city by themselves, without the safeguard of their numerous
friends in the multitude. The answer of Jesus to this report of their
means of resistance was not in a tone to excite them to the very
zealous use of them. He simply said, “It is enough,” a phrase which
was meant to quiet them, by expressing his little regard for such a
defense as they were able to offer to him, with this contemptible
armament.

Some have conjectured that this washing of feet (page 97) was a usual rite at the
Paschal feast. So Scaliger, Beza, Baronius, Casaubon and other learned men have
thought. (See Poole’s Synopsis, on John xiii. 5.) But Buxtorf has clearly shown the falsity of
their reasons, and Lightfoot has also proved that it was a perfectly unusual thing, and that
there is no passage in all the Rabbinical writings which refers to it as a custom. It is
manifest indeed, to a common reader, that the whole peculiar force of this ablution, in this
instance, consisted in its being an entirely unusual act; and all its beautiful aptness as an
illustration of the meaning of Jesus,――that they should cease their ambitious strife for
precedence,――is lost in making it anything else than a perfectly new and original
ceremony, whose impressiveness mainly consisted in its singularity. Lightfoot also illustrates
the design of Jesus still farther, by several interesting passages from the Talmudists,
showing in what way the ablution would be regarded by his disciples, who like other Jews
would look upon it as a most degraded action, never to be performed except by inferiors to
superiors. These Talmudic authorities declare, that “Among the duties to be performed by
the wife to her husband, this was one,――that she should wash his face, his hands and his
feet.” (Maimonides on the duties of women.) The same office was due from a son to his
father,――from a slave to his master, as his references show; but he says he can find no
precept that a disciple should perform such a duty to his teacher, unless it be included in
this, “The teacher should be more honored by his scholar than a father.”

He also shows that the feet were never washed separately, with any idea of legal
purification,――though the Pharisees washed their hands separately with this view, and the
priests washed their hands and feet both, as a form of purification, but never the feet alone.
And he very justly remarks upon all this testimony, that “the farther this action of Christ
recedes from common custom, the higher its fitness for their instruction,――being
performed not merely for an example but for a precept.” (Lightfoot’s Horae Hebraica in
Gospel of John xiii. 5.)

Laid aside his garments.――The simple dress of the races of western Asia, is always
distinguishable into two parts or sets of garments,――an inner, which covered more or less
of the body, fitting it tightly, but not reaching far over the legs or arms, and consisted either
of a single cloth folded around the loins, or a tunic fastened with a girdle; sometimes also a
covering for the thighs was subjoined, making something like the rudiment of a pair of
breeches. (See Jahn Archaeologia Biblica § 120.) These were the permanent parts of the
dress, and were always required to be kept on the body, by the common rules of decency.
But the second division of the garments, (“superindumenta,” Jahn,) thrown loosely over the
inner ones, might be laid aside, on any occasion, when active exertion required the most
unconstrained motion of the limbs. One of these was a simple oblong, broad piece of cloth,
of various dimensions, but generally about three yards long, and two broad, which was
wrapped around the body like a mantle, the two upper corners being drawn over the
shoulders in front, and the rest hanging down the back, and falling around the front of the
body, without any fastenings but the folding of the upper corners. This garment was called
by the Hebrews ‫ שמלה‬or ‫שלמה‬, (simlah or salmah,) and sometimes ‫( ;בגד‬begedh;)――by the
Greeks, ἱματιον. (himation.) Jahn Archaeologia Biblica. This is the garment which is always
meant by this Greek word in the New Testament, when used in the singular
number,――translated “cloak” in the common English version, as in the passage in the text
above, where Jesus exhorts him that has no sword to sell his cloak and buy one. When this
Greek word occurs in the plural, (ἱματια, himatia,) it is translated “garments,” and it is
noticeable that in most cases where it occurs, the sense actually requires that it should be
understood only of the outer dress, to which I have referred it. As in Matthew xxi. 8, where it
is said that the people spread their garments in the way,――of course only their outer ones,
which were loose and easily thrown off, without indecent exposure. So in Mark xi. 7, 8: Luke
xix. 35. There is no need then, of supposing, as Origen does, that Jesus took off all his
clothes, or was naked, in the modern sense of the term. A variety of other outer garments in
common use both among the early and the later Jews, are described minutely by Jahn in
his Archaeologia Biblica, § 122. I shall have occasion to describe some of these, in
illustration of other passages.

My exegesis on the passage “He that is washed, needs not,” &c. may strike some as
rather bold in its illustration, yet if great authorities are necessary to support the view I have
taken, I can refer at once to a legion of commentators, both ancient and modern, who all
offer the same general explanation, though not exactly the same illustration. Poole’s
Synopsis is rich in references to such. Among these, Vatablus remarks on the need of
washing the feet of one already washed, “scil. viae causa.” Medonachus says of the feet,
“quos calcata terra iterum inquinat.” Hammond says, “he that hath been initiated, and
entered into Christ, &c. is whole clean, and hath no need to be so washed again, all over.
All that is needful to him is the daily ministering of the word and grace of Christ, to cleanse
and wash off the frailties, and imperfections, and lapses of our weak nature, those feet of
the soul.” Grotius says, “Hoc tantum opus ei est, ut ab iis se purget quae ex occasione
nascuntur. Similitudo sumpta ab his qui a balneo nudis pedibus abeunt.” Besides these and
many others largely quoted by Poole, Lampius also (in commentary in Gospel of John) goes
very fully into the same view, and quotes many others in illustration. Wolfius (in Cur.
Philology) gives various illustrations, differing in no important particular, that I can see, from
each other, nor from that of Kuinoel, who calls them “contortas expositiones,” but gives one
which is the same in almost every part, but is more fully illustrated in detail, by reference to
the usage of the ancients, of going to the bath before coming to a feast, which the disciples
no doubt had done, and made themselves clean in all parts except their feet, which had
become dirtied on the way from the bath. This is the same view which Wolf also quotes
approvingly from Elsner. Wetstein is also on this point, as on all others, abundantly rich in
illustrations from classic usage, to which he refers in a great number of quotations from
Lucian, Herodotus, Plato, Terence and Plutarch.

Sift you as wheat.――The word σινιαζω (siniazo) refers to the process of winnowing the
wheat after threshing, rather than sifting in the common application of the term, which is to
the operation of separating the flour from the bran. In oriental agriculture the operation of
winnowing is performed without any machinery, by simply taking up the threshed wheat in a
large shovel, and shaking it in such a way that the grain may fall out into a place prepared
on the ground, while the wind blows away the chaff. The whole operation is well described
in the fragments appended to Taylor’s editions of Calmet’s dictionary, (Hund. i. No. 48, in
Vol. III.) and is there illustrated by a plate. The phrase then, was highly expressive of a
thorough trial of character, or of utter ruin, by violent and overwhelming misfortune, and as
such is often used in the Old Testament. As in Jeremiah xv. 7. “I will fan them with a fan,”
&c. Also in li. 3. In Psalm cxxxix. 2. “Thou winnowest my path,” &c.; compare translation
“Thou compassest my path.” The same figure is effectively used by John the Baptist, in
Matthew iii. 12, and Luke iii. 17.

Galilean pugnacity.――Josephus, who was very familiar with the Galileans by his
military service among them, thus characterizes them. “The Galileans are fighters even from
infancy, and are every where numerous, nor are they capable of fear.” Jewish War, book III.
chapter iii. section 2.

From Jerusalem to Jericho.――The English traveler here referred to, is Sir Frederic
Henniker, who in the year 1820, met with this calamity, which he thus describes in his
travels, pp. 284‒289.

“The route is over hills, rocky, barren and uninteresting; we arrived at a fountain, and
here my two attendants paused to refresh themselves; the day was so hot that I was
anxious to finish the journey, and hurried forwards. A ruined building situated on the summit
of a hill was now within sight, and I urged my horse towards it; the janissary galloped by me,
and making signs for me not to precede him, he rode into and round the building, and then
motioned me to advance. We next came to a hill, through the very apex of which has been
cut a passage, the rocks overhanging it on either side. Quaresmius, (book vi. chapter 2.)
quoting Brocardus, 200 years past, mentions that there is a place horrible to the eye, and
full of danger, called Abdomin, which signifies blood; where he, descending from Jerusalem
to Jericho, fell among thieves. I was in the act of passing through this ditch, when a bullet
whizzed by, close to my head; I saw no one, and had scarcely time to think, when another
was fired some distance in advance. I could yet see no one,――the janissary was beneath
the brow of the hill, in his descent; I looked back, but my servant was not yet within sight. I
looked up, and within a few inches of my head were three muskets, and three men taking
aim at me. Escape or resistance were alike impossible. I got off my horse. Eight men
jumped down from the rocks, and commenced a scramble for me; I observed also a party
running towards Nicholai. At this moment the janissary galloped in among us with his sword
drawn.

“A sudden panic seized the janissary; he cried on the name of the Prophet, and galloped
away. As he passed, I caught at a rope hanging from his saddle. I had hoped to leap upon
his horse, but found myself unable;――my feet were dreadfully lacerated by the honey-
combed rocks――nature would support me no longer――I fell, but still clung to the rope. In
this manner I was drawn some few yards, till, bleeding from my ancle to my shoulder, I
resigned myself to my fate. As soon as I stood up, one of my pursuers took aim at me, but
the other casually advancing between us, prevented his firing; he then ran up, and with his
sword, aimed such a blow as would not have required a second; his companion prevented
its full effect, so that it merely cut my ear in halves, and laid open one side of my face; they
then stripped me naked.

“It was now past mid-day, and burning hot; I bled profusely,――and two vultures, whose
business it is to consume corpses, were hovering over me. I should scarcely have had
strength to resist, had they chosen to attack me. At length we arrived about 3 P. M. at
Jericho.――My servant was unable to lift me to the ground; the janissary was lighting his
pipe, and the soldiers were making preparations to pursue the robbers; not one person
would assist a half-dead Christian. After some minutes a few Arabs came up and placed me
by the side of the horse-pond, just so that I could not dip my finger into the water. This pool
is resorted to by every one in search of water, and that employment falls exclusively upon
females;――they surrounded me, and seemed so earnest in their sorrow, that,
notwithstanding their veils, I almost felt pleasure at my wound. One of them in particular
held her pitcher to my lips, till she was sent away by the Chous;――I called her, she
returned, and was sent away again; and the third time she was turned out of the yard. She
wore a red veil, (the sign of not being married,) and therefore there was something
unpardonable in her attention to any man, especially to a Christian; she however returned
with her mother, and brought me some milk. I believe that Mungo Park, on some dangerous
occasion during his travels, received considerable assistance from the compassionate sex.”

the scenes of gethsemane.

After much more conversation and prayer with his disciples in the
supper-room, and having sung the hymn of praise which usually
concluded the passover feast among the Jews, Jesus went with
them out west of the city, over the brook Kedron, at the foot of the
Olive mount, where there was a garden, called Gethsemane, to
which he had often resorted with his disciples, it being retired as well
as pleasant. While they were on the way, a new occasion happened
of showing Peter’s self-confidence, which Jesus again rebuked with
the prediction that it would too soon fail him. He was telling them all,
that events would soon happen that would overthrow their present
confidence in him, and significantly quoted to them the appropriate
passage in Zechariah xiii. 7. “I will smite the shepherd, and the
sheep shall be scattered.” Peter, glad of a new opportunity to assert
his steadfast adherence to his Master, again assured him that,
though all should be offended, or lose their confidence in him, yet
would not he; but though alone, would always maintain his present
devotion to him. The third time did Jesus reply in the circumstantial
prediction of his near and certain fall. “This day, even this night,
before the cock crow twice, thou shalt deny me thrice.” This repeated
distrustful and reproachful denunciation, became, at last, too much
for Peter’s warm temper; and in a burst of offended zeal, he declared
the more vehemently, “If I should die with thee, I will not deny thee in
any wise.” To this solemn protestation against the thought of
defection, all the other apostles present gave their word of hearty
assent.

VALLEY OF THE BROOK KEDRON

between Jerusalem and the Mount of Olives.

John xviii. 1.

They now reached the garden, and when they had entered it,
Jesus spoke to all the disciples present, except his three chosen
ones, saying, “Sit ye here, while I go and pray yonder.” He retired
accordingly into some recess of the garden, with Peter and the two
sons of Zebedee, James and John; and as soon as he was alone
with them, begun to give utterance to feelings of deep distress and
depression of spirits. Leaving them, with the express injunction to
keep awake and wait for him, he went for a short time still farther,
and there, in secret and awful woe, that wrung from his bowed head
the dark sweat of an unutterable agony, yet in submission to God, he
prayed that the horrible suffering and death to which he had been so
sternly devoted, might not light on him. Returning to the three
appointed watchers, he found them asleep! Even as amid the lonely
majesty of Mount Hermon, human weakness had borne down the
willing spirit in spite of the sublime character of the place and the
persons before them; so here, not the groans of that beloved
suffering Lord, for whom they had just expressed such deep regard,
could keep their sleepy eyes open, when they were thus exhausted
with a long day’s agitating incidents, and were rendered still more
dull and stupid by the chilliness of the evening air, as well as the
lateness of the hour of the night; for it was near ten o’clock. At this
sad instance of the inability of their minds to overcome the frailties of
the body, after all their fine protestations of love and zeal, he mildly
and mournfully remonstrates with Peter in particular, who had been
so far before the rest in expressing a peculiar interest in his Master.
And he said to Peter, “Simon! sleepest thou? What! could ye not
watch with me one hour? Watch ye and pray, lest ye enter into
temptation. The spirit indeed is willing, but the flesh is weak.” Well
might he question thus the constancy of the fiery zeal which had so
lately inspired Peter to those expressions of violent attachment.
What! could not all that warm devotion, that high pride of purpose,
sustain his spirit against the effects of fatigue and cold on his body?
But they had, we may suppose, crept into some shelter from the cold
night air, where they unconsciously forgot themselves. After having
half-roused them with this fruitless appeal, he left them, and again
passed through another dreadful struggle between his human and
divine nature. The same strong entreaty,――the same mournful
submission,――were expressed as before, in that moment of solitary
agony, till again he burst away from the insupportable strife of soul,
and came to see if yet sympathy in his sorrows could keep his
sleepy disciples awake. But no; the gentle rousing he had before
given them had hardly broken their slumbers. For a few moments the
voice of their Master, in tones deep and mournful with sorrow, might
have recalled them to some sense of shame for their heedless
stupidity; and for a short time their wounded pride moved them to an
effort of self-control. A few mutual expostulations in a sleepy tone,
would pass between them;――an effort at conversation perhaps,
about the incidents of the day, and the prospect of coming danger
which their Master seemed to hint;――some wonderings probably,
as to what could thus lead him apart to dark and lonely
devotion;――very likely too, some complaint about the cold;――a
shiver――a sneeze,――then a movement to a warmer attitude, and
a wrapping closer in mantles;――then the conversation languishing,
replies coming slower and duller, the attitude meanwhile declining
from the perpendicular to the horizontal, till at last the most wakeful
waits in vain for an answer to one of his drowsy remarks, and finds
himself speaking to deaf ears; and finally overcome with impatience
at them and himself, he sinks down into his former deep repose, with
a half-murmured reproach to his companions on his lips. In short, as
every one knows who has passed through such efforts, three sleepy
men will hardly keep awake the better for each other’s company; but
so far from it, on the contrary, the force of sympathy will increase the
difficulty, and the very sound of drowsy voices will serve to lull all the
sooner into slumber. In the case of the apostles too, who were
mostly men accustomed to an active life, and who were in the habit
of going to bed as soon as it was night, whenever their business
allowed them to rest, all their modes of life served to hasten the
slumbers of men so little inured to self-control of any kind. These
lengthy reasons may serve to excite some considerate sympathy for
the weakness of the apostles, and may serve as an apology for their
repeated drowsiness on solemn occasions; for a first thought on the
subject might suggest to a common man, the irreverent notion, that
those who could slumber at the transfiguration of the Son of God on
Mount Hermon, and at his agony in Gethsemane, must be very